Name:       
PeopleSoft ID:       
Permanent Address:       
City, State, Zip:       
Phone:    (example: 555-555-5555)   
Email Address:    (example: Joe.Husky@uconn.edu)   
Current Major:       
Previous and/or Future Majors:       
Academic Advisor:       
Are you currently enrolled in any Summer classes?     Yes    No

If you answered yes above, please enter where you are taking classes:

Please list the intercession courses in which you are enrolled or plan to enroll:     1)
2)
3)
4)    

Please provide an explanation of the circumstances that contributed to your academic difficulty:

   

Will you be including documentation via mail, fax, or other means regarding your circumstances (e.g., medical documentation, court records, etc.)?

  Yes    No

Please describe your long-term goals including your academic plans for the next semester and beyond:   
   

Note: The information you provide on this form is secured to protect your privacy and confidentiality. This form is submitted directly to Christine Mosman, member of the Torrington Campus Dismissal Committee.